The American College of Rheumatology (ACR) has issued clinical guidance for the management of pediatric rheumatic disease (PRD) during the coronavirus disease 2019 (COVID-19) pandemic. The full report is published on the ACR website.
To develop guidance for the management of children with rheumatic disease, the North American Pediatric Rheumatology Clinical Guidance Task Force, including 7 pediatric rheumatologists, 2 pediatric infectious disease physicians, 1 adult rheumatologist, and 1 pediatric nurse practitioner, was convened by the ACR on May 21, 2020. The task force generated an evidence report based on literature reviews and developed guidance statements accordingly, following which the members voted on the statements to achieve consensus. A 9-point scale was used to evaluate each statement, with consensus rated as low, moderate, or high.
Recommendations for PRD Management During COVID-19
General Guidance for Patients With PRD
- Rheumatology providers should advise children and families of children with PRD to follow general preventative measures, including social distancing, hand washing, and using masks or face coverings, to limit potential exposure to COVID-19.
- Caregivers of children with PRD may be at risk for occupational exposure to infection with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and should be counseled on Centers for Disease Control (CDC) health and safety practices in the workplace.
- Rheumatology providers should consider the clinical assessment and treatment of rheumatic disease via telemedicine to ensure access to care during increased community transmission of COVID-19.
- Routine ophthalmologic surveillance of patients with PRD at high risk for chronic uveitis or with a history of uveitis should be continued via in-person visits, using slit lamp examination.
- Children with PRD should be recommended to continue routine childhood vaccinations, including the annual influenza vaccine, unless they are contraindicated due to disease modifying antirheumatic drug (DMARD) therapy.
- Children and caregivers of children with PRD may be at risk for mental health illnesses, anxiety, and depression because of remaining in quarantine and other events in the context of COVID-19.
- In children with PRD, the SARS-CoV-2 antibody testing may not be useful in indicating history of infection or risk for reinfection with COVID-19.
Ongoing Treatment of PRD in the Absence of SARS-CoV-2 Exposure or Infection
- Treatment with nonsteroidal anti-inflammatory drugs (NSAIDs), hydroxychloroquine, angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, colchicine, and conventional, biologic, and targeted synthetic DMARDs (cDMARDs, bDMARDs, and tsDMARDs, respectively) may be initiated or continued to control the underlying disease.
- Rheumatology providers may initiate or continue treatment with glucocorticoids, using the lowest dose possible.
- Patients with PRD with life and/or organ threatening manifestations may be initiated with treatment with high-dose oral or intravenous “pulse” glucocorticoids to control the underlying disease.
- To control the underlying disease, rheumatology providers may also initiate or continue cyclophosphamide in patients with PRD with life and/or organ threatening manifestations.
- For patients with PRD with active arthritis, intra-articular glucocorticoid injections may be administered.
- For patients with stable PRD with previously stable laboratory markers, and receiving stable doses of cDMARDs, bDMARDs, and/or tsDMARDs, rheumatology providers may extend laboratory testing intervals to monitor medication toxicity and reduce potential exposure to SARS-CoV-2.
- Laboratory monitoring for disease activity should be continued according to standard practices to ensure adequate assessment and control of the underlying disease.
- The task force has recommended that de-escalation of therapy may be continued in patients with PRD; however, the potential risk for disease flares and barriers to follow-up must be considered.
Ongoing Treatment of PRD With Close/Household Exposure to COVID-19
- For patients with close/household exposure to COVID-19, general preventative measures, including social distancing, hand washing, and wearing face coverings, should be strongly recommended to reduce risk for infection with SARS-CoV-2.
- Treatment with NSAIDs, hydroxychloroquine, colchicine, cDMARDs, bDMARDs, and/or tsDMARDs may be initiated, if necessary, or continued.
- Patients with PRD may continue to receive the lowest possible dose of glucocorticoids to control the underlying disease.
- For patients with PRD that is not life and/or organ threatening, initiation of high-dose oral or intravenous glucocorticoids should be delayed for 1 to 2 weeks, if considered safe.
- For patients with PRD with life and/or organ threatening manifestations of PRD, initiation of high-dose oral or intravenous glucocorticoids should not be delayed.
Ongoing Treatment of PRD and Asymptomatic COVID-19 Infection
- Treatment with NSAIDs, hydroxychloroquine, colchicine, cDMARDs, bDMARDs, and/or tsDMARDs may be continued, if necessary, to control the underlying disease.
- Patients with PRD may also continue to receive cyclophosphamide or rituximab.
- Rheumatology providers should continue treatment with the lowest possible dose of glucocorticoids to control the underlying disease and avoid adrenal insufficiency.
Ongoing Treatment of PRD and Suspected or Confirmed Symptomatic COVID-19 Infection
- Treatment with NSAIDs, hydroxychloroquine, and colchicine may be continued, if necessary, to control the underlying disease.
- Rheumatology providers should consider temporarily delaying or withholding treatment with cDMARDs, bDMARDs (except interleukin [IL]-1 and IL-6 inhibitors), and tsDMARDs.
- Treatment with IL-1 and IL-6 inhibitors may be continued, if necessary.
- Glucocorticoids should be continued with the lowest possible dose to control the underlying disease and avoid adrenal insufficiency.
American College of Rheumatology. COVID-19 clinical guidance for pediatric patients with rheumatic disease. Updated June 17, 2020. Accessed June 23, 2020. https://www.rheumatology.org/Portals/0/Files/COVID-19-Clinical-Guidance-Summary-for-Pediatric-Patients-with-Rheumatic-Disease.pdf